Hillcrest Nursing Center

In the surveyor’s words

From the most serious findings on record at Hillcrest Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 27, 2021

  Based on observation, interview, record review and facility policy review the facility failed to prevent the possible spread of foodborne illness for 83 of 89 residents residing in the facility. Findings Include: A review of the facility's policy, Food Storage Labeling, revision date 5/2018, the facility will ensure the safety and quality of food by following good storage and labeling procedures. The facility's, policy, Recommended Food Storage Chart, dated 9/2012, condiments open 6 months in cooler and salad dressing open 3 months in cooler. On 08/24/21 at 10:33 AM, an initial tour of the kitchen with the Interim Dietary Manager (IDM) revealed the following: The walk in cooler contained a one (1) gallon sweet pickle relish, 1/3 full, with an opened date of 6/30 with no year indicated. […]

• No harm, potential for more than minimal, patternF812Jul 16, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to store food in accordance with professional standards by not removing expired food product, and not labeling or dating opened or prepared food items for one (1) of two (2) kitchen observations.Findings include:A review of the facility's policy, Food Storage Labeling, revised 8/12, revealed, Policy: The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedures. Procedure: 1. Labeling a. All temperature-controlled foods and ready-to-eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food.Date of storage.3. Rotation.b. […]

• No harm, potential for more than minimal, isolatedF550Jul 16, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to dignity by entering the residents' room without knocking for one (1) of eighteen (18) residents sampled. Resident #20.Findings include:A review of the facility's policy, Dignity and Respect, revised 07/22, revealed A facility must treat each resident with respect and dignity.The facility shall protect the rights of the resident.6. All staff, regardless of department, should knock and wait for a response before entering any resident's room.On 07/13/2026 at 2:08 PM, during an observation of the residents' halls, Certified Nursing Assistant (CNA) #1 entered Resident #20's room twice without knocking on her door. […]

• No harm, potential for more than minimal, isolatedF584Jul 16, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to comfortable hot water temperatures for one (1) of three (3) resident rooms reviewed, (Resident #53).Findings include:A review of the facility's document entitled Water Temperature revised 08/00, revealed, Procedure: The temperature of hot water at plumbing fixtures used by residents shall not exceed 115 degrees Fahrenheit and no less than 100 degrees Fahrenheit.On 7/13/2026 at 12:30 PM, during an interview and observation, Resident #53 was seated in a wheelchair. Resident #53 explained the hot water at the bathroom sink did not get hot. The resident stated the Maintenance Director had been informed of the problem, but it had been corrected. […]

• No harm, potential for more than minimal, isolatedF836Jul 16, 2026

  Based on interview, record review, and facility policy review, the facility failed to comply with state nursing facility staffing requirements by failing to ensure the nursing staff had a ratio of 2.8 hours of direct nursing care per resident per twenty-four (24) hours for two (2) of 13 days reviewed in the Second Quarter (January, February, and March) of 2026).Findings include:A record review of the facility's policy, Nursing Services - Staffing, with a revision date of 02/2026, revealed, .The facility will comply with established staffing requirements by the individual state governing agencies. […]